At the end of the manual describing mental disorders (DSM-IV) the American Psychiatric Association has a chapter titled “Other Conditions That May Be a Focus of Clinical Attention.” After 675 pages describing mental disorders, this brief chapter lists conditions that are NOT mental disorders, but they may be distressing to individuals or interfere with their functioning. These other conditions have a “V” before their code number, and they include the following as well as many others.

V62.2 Occupational Problem

V62.3 Academic Problem

V62.4 Acculturation Problem

V62.82 Bereavement

V62.89 Religious or Spiritual Problem

Just as normal individuals may have a problem with work, with school, or with grief, they may also have an “Acculturation Problem.” The DSM-IV says only, “This category can be used when the focus of clinical attention is a problem involving adjustment to a different culture (e.g., following migration).” Although the DSM-IV does not elaborate on this problem experienced by normal people, a description of what it might be like for ordinary missionaries who reenter their passport countries is helpful. We have written the following description.

Acculturation Problem

(The Reentry Transition)

Diagnostic Features

When reentering their passport culture many people experience the Acculturation Problem that some people have called “reverse culture shock.” During the time these people were in their host culture, both they and their passport culture have changed, so they become aliens in their own country. They find that, rather than feeling at home where there are routine interactions, predictable events, and few surprises, the environment is confusing and even disgusting or “wrong.” Rather than feeling safe and secure where they can trust their instincts and be themselves, they feel vulnerable, anxious, fearful, and always have to think about what they do. This is often disconcerting because if people do not feel like they belong at home, where do they belong?

Such people may experience great disappointment when their expectations are not met. They may become angry and then allow the anger to become resentment or bitterness. They may become alienated, critical, or maybe cynical. In their frustration they may withdraw from people, even family, so that they become isolated and lonely. They may find themselves being easily offended, judgmental about their home culture, and even depressed. They may become angry at their culture for the great materialism they see, especially the great wastefulness as they see “good, useable” things discarded. These feelings are typically greater if the people had a wonderful time in their host culture and less if they had a difficult time.

Christian missionaries may become disillusioned by the church in their passport country, even by their “home church.” As one returning missionary put it, “Our church is comatose and doesn’t even know it.” Experiencing the different worship styles, they sense a lack of spirituality in the churches they visit. When there is little response to their impassioned pleas for help for people in their host culture, they may perceive a great apathy in the church in general.

When returning home, they may see familiar faces, but not familiar people. Both they and the people they knew have changed. “Familiar” places are not familiar any more. When returning to the same church, they find that the people there are not really the same anymore; they have little in common, and they cannot break into the group again. People back home seem to have such narrow perspectives on events, and the returning ones do not know where they fit, so they sense that they are forming temporary relationships. They miss the closeness of the expatriate community in their host culture when returning to a culture that places the emphasis on the individual. They may misinterpret gestures and other “signals” so that they become marginal people who must initiate relationships rather than being sought out.

Of course, they must remember that loneliness and unpleasantness are often the beginning of insight and personal growth. In a sense they have become cultural hybrids who are temporarily homeless, at home in neither their passport culture nor in their host culture. However, when they are able to put their cross-cultural experience in perspective and see how it relates to their whole life story, they usually find out that they can still hold on to their new values and attitudes and once again feel at home in their passport culture.

Associated Features and Problems

Several other problems may occur simultaneously with the Acculturation Problem. Since the nature of work is likely to change following repatriation, a V62.2 Occupational Problem may occur. Returning to their passport country people often find their work increasing in security but decreasing in significance. Instead of being in charge, they often are expected to blend into their agency with everyone else. Likewise schools are likely to be different for children and adolescents. Instead of home schooling or schools with small classes, they may find themselves in large schools with a resulting V62.3 Academic Problem. Note that these are V-codes, and not mental disorders.

Religious people may develop a V62.89 Religious or Spiritual Problem. Religious people may experience the normal anger, cynicism and depression and come to the conclusions that something is wrong with their religion. Even though nothing is wrong, this can lead to a spiritual problem. Missionaries in particular changing from “religious work” to raising money may feel guilty about not doing what God had called them to. Again note that this is a V-code, and not a mental disorder.

Mental disorders such as a 300.02 Generalized Anxiety Disorder or a 296.2 Major Depressive Disorder may develop if the normal anxiety or depression associated with an Acculturation Problem lasts for an extended period of time. These are mental disorders and individuals with these long-term problems should seek help from a mental health professional.

Specific Culture, Age, and Gender Features

Children are often quite verbal about not wanting to return to their parents’ passport country, but they usually adjust quite rapidly. The younger they are, the more rapidly they adjust. Within a few days or weeks younger children make new friends and are playing happily with them.

Adolescents, likewise, may not want to return. Relationships with one’s peers are extremely important during the teen years. Suddenly leaving peers and trying to break into a new group in a society of teenagers can be a very difficult task, so adolescents may want to avoid it and have great difficulty when forced to do so. This may involve acting out and result in getting into serious trouble.

Relationships are also very important to women. Giving up a close-knit group of friends on the field and trying to find like-minded women in her passport country may be difficult, especially since many may be working.

Men are more likely to experience a loss of identity as their job changes. On the field they may be involved in anything from church planting to construction to teaching. On home assignment they are often on the road raising funds to go back. As one man put it he was going through “making a difference withdrawal.” On the field he made the difference between life and death, but back home, if he were not there, people in need could just go to someone else.

Familial Pattern

What we call “reentry” for missionary kids may not be reentry at all, but really entry to a “foreign” country. That is, they are entering the country from which their parents came, but they have never really lived there any length of time themselves. They may have visited grandparents and other relatives there briefly, but real home for them is what their parents call their host country. Thus, their Acculturation Problem is one of entry, not reentry.

Prevalence

Experiencing the Acculturation Problem upon reentry is very common in that about two-thirds of the people who return to their passport country experience significant discomfort. The other one-third reenter with little difficulty beyond a relatively rapid adjustment to technological changes. People usually expect an Acculturation Problem when entering their host culture because of the widely used term “culture shock.” However, upon returning to their passport culture many people are surprised to find that there is a “reverse culture shock,” and that it is often even a more difficult adjustment.

Acculturation Problems may occur each time one changes cultures. Some people report each successive reentry becomes easier, probably because they expect the problems and have learned how to adapt to them. Other people find successive reentries more difficult, particularly if the latter ones involve leaving children and/or grandchildren in the host country.

Course

Each episode typically includes three stages: leaving, “in between,” and entering. The “leaving” stage begins several weeks or months before actual departure when the missionaries start anticipating the return “home” and separating from the work in the host country. This stage is marked by receiving attention and recognition from others at receptions; saying goodbye to persons, places, and pets; withdrawing from their work as they turn it over to others, and generally bringing closure to their time on the field. At this time they are disengaging from their past and turning their attention toward their future. They may be in denial that it is already time to return and have feelings of rejection, resentment and sadness.

The “in between” stage begins when the missionaries leave for the airport and end when they unpack their minds, not their suitcases. During this time they are without status, structure, and even keys. In this time of chaos they may feel overwhelmed and isolated, as well as exaggerating their problems. Their self-esteem may drop and they may become anxious over the future and grieving over their losses in the recent past.

The “entering” stage begins when the missionaries have unpacked their minds and continues until the missionaries have re-engaged with their passport culture. During this time they realize that they are marginal persons and are in rather superficial, tentative relationships. Reentering missionaries may misinterpret verbal and nonverbal behaviors and make errors in responding. They may feel vulnerable, fearful, and may be easily offended. They may find it difficult to trust people and even experience depression. Some experience a “honeymoon” period immediately after they reenter when everything is seen through rose-colored glasses. Then this may be followed by a period of disillusionment when everything is viewed through rust-colored glasses so that they notice materialism and superficiality in their home culture. During this time they may become angry, judgmental, bitter, lonely, fearful and isolated.

This entering stage may take only a few months, or a year (a full annual cycle), or never be completed. Some missionaries are unable to complete this stage and remain disillusioned for the rest of their lives. Some return to their host culture after retirement to spend their final days there.

Some say that people know they have fully reentered their passport culture when they do the following things.

They stop carrying toilet paper everywhere.

They are not afraid to swallow water while showering.

They do not get nervous when they eat lettuce.

They drink water with ice in it.

They buy cherries or grapes along the highway and eat them.

They use tissues to blow their noses.

Again note that an Acculturation Problem is not a mental disorder, but people who do experience in should know that it is normal. Those who do not have similar reactions, thoughts, or feelings need to be aware of the problems other normal missionaries face. Also note that the above description is written for this booklet—all the DSM-IV says about it is “This category can be used when the focus of clinical attention is a problem involving adjustment to a different culture (e.g., following migration).”